Abstract
Background
Multiple sclerosis (MS) is a chronic autoimmune disease caused by demyelination in the central nervous system primarily affecting younger adults leading to disability due to sensorimotor deficits and cognitive impairment. Online search volume index (SVI) can be used as a surrogate marker to explore interest and awareness for MS in the Philippines.
Objectives
This study aimed to describe the online searching behavior and interest for MS in the Philippines and explored its implications in the current healthcare situation surrounding the disease in the country.
Methods
Using Google Trends, the monthly SVI for the term “Multiple Sclerosis” from 1 January 2014 to 31 July 2024 in the Philippines was determined and its related queries. Philippine data was compared with worldwide data by using Spearman rank correlation, and MS SVI was compared with top neurologic diseases in the Philippines.
Results
The SVI for MS generally remained in the same level over the last 10 years, with only two peaks, and no seasonal or annual variation observed. Worldwide SVI trends did not correlate with Philippine SVI trends. SVI for MS ranked the lowest in comparison to the top four neurologic diseases in the Philippines.
Conclusion
SVI trends of MS in the Philippines mirrored its prevalence and incidence, current state of healthcare delivery, and research productivity in the country. This signals opportunities to increase awareness for MS and capacity of the healthcare system to adequately diagnose and treat said disease entity.
Introduction
Multiple sclerosis (MS) is a chronic autoimmune disease caused by demyelination in the central nervous system, primarily affecting younger adults (18–40 years old), that can lead to disability due to sensorimotor deficits and cognitive impairment. 1 The chronic nature of MS can present with multiple separate attacks of new-onset neurologic symptoms (relapsing-remitting variant), or a steady progressive deterioration of neurologic function (primary or secondary progressive variant). Since its clinical presentation mimics numerous neurologic diseases, diagnosis of MS uses a combination of clinical, radiologic, and cerebrospinal fluid studies to increase accuracy of detecting cases. 1
MS affects around 1.89 million people worldwide with 16,000 deaths attributable to the disease. 2 Although MS is known to be more prevalent in the western hemisphere, local cases are still present. MS is known as a neglected neurologic disease entity in Asia, with no published local epidemiologic data available among Southeast Asian countries.3,4 A study focusing on the 2019 data on burden of neurologic disease in Asia estimates MS to occur in around 8 in 100,000 people. 5 In the Philippines, its incidence remains unknown since there are no registries or published epidemiologic studies documenting its incidence and prevalence on a national scale. Moreover, despite advancement in the diagnosis and increase in the medications available for disease control of MS in the global market, the Philippines remains limited in the availability for diagnostic procedures and management options. 6
Infodemiologic studies are a relatively new way of investigating the interest of a population regarding a certain entity by using queries made on the internet. In the field of public health, it can be used to decipher the determinants and distribution of a disease entity in the electronic platform.7,8 Since the COVID-19 pandemic, numerous infodemiologic studies were done to assess distribution of health information and explore health-seeking behavior of the public. Google Trends is one of the most common platforms used, which makes use of real-time data of search behavior using hits from the Google search engine. Its advantage stems from Google having the biggest market share among the internet search engines available to the public. 8 In the absence of local epidemiological data on MS, we have chosen to utilize infodemiology to gauge the awareness and interest of the Philippine population on MS. This study aimed to describe the online searching behavior and interest for MS in the Philippines and explored its implications in the current healthcare situation surrounding the disease in the country.
Methodology
This is a primarily descriptive study of the monthly searches from Google of the term “Multiple Sclerosis” as retrieved from Google Trends. Data obtained for the study started from 1 January 2014 to 31 July 2024, with “Philippines” as the chosen region. There is no known direct translation of MS in Filipino, or any local health concepts that closely refer to MS; hence, it is the only term analyzed. Search volume indices (SVI) for MS were generated and analyzed for the specified time period, together with related top searches and queries. The SVI refers to a normalized value (from 0 to 100) reflecting the volume of searches in a month, relative to the total search volume in a specified time period. SVI does not reflect the actual number of searches generated in certain time period. 8 In addition, top- and rising-related queries were included. Top-related queries refer to the most popular searches that were made by users searching for “Multiple Sclerosis” in the requested period of time, while rising-related queries are search terms with the highest increase in frequency within the specified time period. Top-related values are expressed in terms of SVI, and rising-related values are expressed in terms of percent increase.
For comparison, SVI for the top four neurologic diseases by prevalence in the Philippines—stroke, migraine, dementia, meningitis—as detailed in the 2019 Common Burden of Neurologic Disease study in Asia 5 were generated and compared with MS. In addition, worldwide trends over time for “Multiple Sclerosis” were included to determine the position of the Philippines in terms of SVI globally.
Statistical analysis
Spearman rank correlation was conducted to assess if variability and changes in Philippine SVI data is correlated with worldwide SVI data. This was analyzed using JASP 0.19.3, an open-source statistical software.
Results
From 2014 to 2024, the SVI for MS remained in the same level, with 2 peaks: November 2015 with 62 and August 2017 with 100 (Figure 1). The SVI of 127 months was included in the data set (26.465 ± 9.326). Within each year, no seasonal or annual variations were observed. Worldwide, the Philippines ranked 11th in terms of interest over time with an SVI of 46, as shown in Table 1. Spearman's correlation yielded a coefficient of 0.065, indicating a weak correlation between worldwide and Philippine SVI trends. The top regions in the Philippines with the highest SVI were the Cordillera Administrative Region, Autonomous Region of Muslim Mindanao, Central Visayas, Zamboanga Peninsula, and Metro Manila.
Search volume index for multiple sclerosis for the Philippines and worldwide.
Search volume index for multiple sclerosis worldwide and per region in the Philippines.
MIMAROPA: Mindoro, Marinduque, Romblon, Palawan; SVI: search volume index.
A google search performed investigating MS during the aforementioned peak months revealed two events involving Filipino celebrities. Despite these peaks, SVI for MS were not sustained and quickly returned back to baseline in the succeeding months. SVI for different regions in the Philippines do not show any significant difference with each other.
Majority of the top-related search queries for MS are about the disease itself—definition, signs and symptoms, and treatment. Other-related queries were on other neurologic disorders, such as myasthenia gravis and Parkinson's disease. All of the rising-related search hits had a percent increase of >5000%, indicating a large increase in search frequency. The rising search-related queries had some similarities to the top-related queries, but had more frequent mentions of other autoimmune and degenerative neurologic conditions, such as amyotrophic lateral sclerosis, and Alzheimer disease [Table 2]. MS has the lowest SVI in comparison with the top four neurologic disorders (stroke, migraine, dementia, and meningitis) with the highest burden in the Philippines [Figure 2, Table 3].
Search volume index of multiple sclerosis and the top four neurologic diseases in the Philippines.
Top and rising search terms for multiple sclerosis in the Philippines.
SVI: search volume index.
Descriptive statistics of the search volume index of multiple sclerosis in comparison to the top four neurologic diseases in the Philippines.
Discussion
In the last decade, search volume index (SVI) for MS in the Philippines did not show any increase, aside from two apparent peaks. Top-related queries were largely about the nature of MS—its meaning and symptomatology, diagnosis, and treatment. No specific symptom, diagnostic test, or medication were seen in the top-related queries. In addition, rising-related queries mostly consisted of other neurologic diseases, particularly neurodegenerative such as Parkinson's disease, Alzheimer disease, and amyotrophic lateral sclerosis. This suggests that the searches made were primarily geared towards obtaining information to acquaint with the disease entity. The lack of specifics in the searches possibly denotes a search behavior driven by curiosity in a novel subject, rather than actively searching to further existing baseline knowledge. There is some difference in the search behavior in comparison to countries with higher SVI and number of diagnosed cases of MS, and in those who are knowledgeable to MS. In countries with high number of cases, MS-specific search terms such as pain, and diagnostics like MRI were present in top- and rising-related queries.9,10 An infodemiologic study of MS in Italy also showed therapy and symptoms as the top-related queries. 10 Search behaviors of caregivers and patients with MS were more related to interventions on prevention and control of disease activity, future treatments, quality of life, and experiences of other patients with MS. 11 A higher baseline knowledge on a specific disease entity likely produces a more specific and targeted searching behavior. Global infodemiologic studies on other neurologic disease entities that showed an increase in interest as evidenced by an upward trajectory in SVI such as in epilepsy and autoimmune encephalitis, showed top-related queries that are more specific in terms of interventions and diagnosis.12,13
In worldwide epidemiological studies exploring MS, developed countries were on top of the list – United States, Australia, Canada, New Zealand, and United Kingdom. 9 The case is still the same for geographic distribution of high SVI in the past 10 years. In this study, the Philippines placed 11th overall worldwide in terms of SVI. This could be accounted for by the large amount of internet users in the country 14 compared to the global average, and by English being an official language of the Philippines. Other factors that may have contributed to this include the unavailability of Google in other countries, and the existence of direct translation of MS into other languages—both of which were not accounted for by the search methodology of this study.
Based on the SVI results, it can be assumed that the trend of search behavior of MS in the Philippines mirror the disease burden and state of awareness of MS in the country. When compared with the top four neurologic diseases (stroke, migraine, dementia, meningitis), 5 the generated SVIs rank the same as their prevalence and incidence. Moreover, the prevalence of MS cases in regions near the equator, which includes the Philippines, are smaller compared to developed countries. Relatively rare diseases like MS are not prioritized in terms of healthcare service delivery, from diagnosis to the number of available medications. Compounding this with financially intensive diagnostic tests (magnetic resonance imaging, oligoclonal bands, other autoimmune work-up) to formally diagnose MS, low- to middle-income countries such as the Philippines are at a disadvantage. The Philippines continues to face the same challenges and treatment gaps as detailed in a study done in 2020. 6 These challenges include limited accessibility and availability of diagnostic modalities, lack of treatment options for MS, and prohibitive costs associated with both. This raises the question whether MS is truly a rare disease in the Philippines or primarily an underdiagnosed one. The relatively low awareness of MS in the Philippines is also seen in its research productivity—the Philippines falls below the global average, and ranks among the lowest in Southeast Asia. As of 2020, there are only five published studies in journals on MS in the Philippines. 15
Similar to other countries, peaks in interest were closely related to news of celebrities or big personalities being diagnosed with MS. Despite MS being prevalent in other countries, peaks in search volume remain largely driven by local celebrities being affected by MS, as evidenced by large search hits in relation to the diagnosis of Selma Blair and Christina Applegate. 9 In the Philippines, the increase in interest in November 2015 was due to a viral interview done by news anchor Karen Davila with Filipina actress Alma Moreno, in relation to her senatorial bid then in the upcoming May 2016 Philippine elections. 16 The said actress was diagnosed with MS, and her diagnosis was a point of consideration with regard to her running for senator. On the other hand, August 2017 was due to news of the death of the son of actor and television host Randy Santiago due to MS. 17 Prominent public figures such as local celebrities could be an effective way of stimulating interest and spreading awareness on MS. Aside from showbusiness-related news, no other event has demonstrated a peak in SVI for MS. Global activities meant to raise awareness for MS such as World MS Day, which is usually celebrated during the month of May, did not lead to any noticeable increase in SVI.
Limitations of this study include inability to reach a fraction of the Philippine population without access to the internet, and those who do not utilize the internet. According to the Women and Information and Communication Technologies Index Survey 2022, 76.9% of Philippine households have access to the internet, while 23.1% do not have access. 14 Moreover, due to only using Google Trends, it is beyond the scope of this study to account for search behavior that occur in other search engines and websites, particularly in social media platforms where health information is also heavily exchanged. Other factors that influence search behavior such as educational level, digital literacy, and differences in languages are not accounted for in this study. Another limitation includes the exclusion of searches for MS using the search term “MS” as an abbreviation. To minimize the risk of including unrelated searches and diluting the SVI of searches possibly not related to MS, this was not included in the search terms for this study. Despite these limitations, this study has demonstrated online search interest for MS in the Philippines. In the absence of actual epidemiological studies that document the prevalence of MS in the Philippines, infodemiologic studies like this can serve as a surrogate marker to explore current healthcare situation surrounding MS in the country.
Conclusion
This study showed that online search interest in MS in the Philippines did not vary in the past 10 years. The absence of an upward trajectory in search interest appears to mirror the current disease burden, and healthcare situation surrounding MS in the Philippines. Significant efforts are still needed to raise awareness of MS in the Philippines. This can be achieved through national health campaigns, incorporating MS education at the basic education level, integrating the topic into mass media, and partnering with global MS organizations. Beyond awareness, the capacity of the healthcare system to detect cases and offer treatment should be strengthened through adequate funding and policy making. Lastly, it is highly recommended to have epidemiological studies and a national registry that account for the prevalence and incidence of MS in the Philippines, for it can serve as basis for future directions in improving delivery of care, and provide avenues in better understanding MS in the local context.
Footnotes
Acknowledgment
None
Author contributions
KJEB did data curation, formal analysis, methodology, writing—original draft, and writing—review and editing. RDGJ did conceptualization, methodology, supervision, and writing—review and editing.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Written informed consent
Informed consent is not applicable for this study since there is no direct participation from any human participant.